The McGill University Health Centre Policy on sentinel events: using a standardized framework to manage sentinel events, facilitate learning and improve patient safety.

Abstract

Promoting a culture of safety within organizations includes translating the lessons learned from sentinel events into concrete changes that will improve patient safety. In May 2005 the McGill University Health Centre Policy on Sentinel Events was implemented to provide a standardized framework to manage these events and promote that culture of safety. This framework helped implement a number of changes to improve patient safety. The O2 Ticket to Ride project ensures cross-disciplinary responsibility for the transportation of oxygen-dependent patients to diagnostic testing areas. The Code Stroke Algorithm was developed to expedite the sequence of events from the time the stroke symptoms are observed to the time the CT scan is carried out.